Pharmacological Reports 67 (2015) 542–544

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Pharmacological Reports
journal homepage: www.elsevier.com/locate/pharep

Short communication

The pharmacokinetic interaction between levofloxacin and sunitinib

Andrzej Czyrski a,*, Katarzyna Kondys a, Edyta Szałek b, Agnieszka Karbownik b,
Edmund Grześkowiak b
a
Department of Physical Pharmacy and Pharmacokinetics, Poznań University of Medical Sciences, Poznań, Poland
b
Department of Clinical Pharmacy and Biopharmacy, Poznań University of Medical Sciences, Poznań, Poland

A R T I C L E I N F O A B S T R A C T

Article history: Background: The aim of this study was to evaluate the impact of sunitinib on pharmacokinetics of
Received 11 August 2014 levofloxacin. The previous study proved that levofloxacin co-administered with sunitib changes the
Received in revised form 29 October 2014 following pharmacokinetic parameters i.e. Cmax and AUC for both sunitinib and SU012662 (sunitinib
Accepted 15 December 2014
metabolite). We will also investigate if the limited sample strategy can be applied for levofloxacin.
Available online 31 December 2014
Methods: Rabbits were divided into two groups. In both groups there were six animals. In the control
group levofloxacin was administered and in investigated group levofloxacin and sunitinib were co-
Keywords:
administered. The dose of levofloxacin was 20 mg/kg and the dose of sunitinib was 25 mg. The
Levofloxacin
Sunitinib
concentration in plasma was determined by HPLC-FLD. The pharmacokinetic parameters were evaluated
Interaction by WinNonLin software. The results were evaluated by the following statistical tests: Shapiro–Wilk, t-
Limited sample strategy Student and Mann–Whitney test.
Results: Pharmacokinetics of levofloxacin obeys the two-compartment model. Sunitinib influences the
following pharmacokinetic parameters of levofloxacin: half-life, elimination constant and volume of
distribution. Statistical analysis proved that there is a correlation between AUC and the following five
time-points: 0.25 h, 4 h, 6 h, 10 h and 12 h.
Conclusions: The study proved that there is a potential pharmacokinetic interaction between sunitinib
and levofloxacin. The statistical analysis proved that the limited sample strategy can be applied for
levofloxacin.
ß 2015 Institute of Pharmacology, Polish Academy of Sciences. Published by Elsevier Urban & Partner Sp.
z o.o. All rights reserved.

Introduction effect and the pharmacodynamic parameters Cmax/MIC and AUC/MIC

Levofloxacin ((S)-9-fluoro-2,3-dihydro-3-methyl-10-(4-methylpi-
perazin-1-yl)-7-oxo-7H-pyrido[1,2,3-de]-1,4-benzoxazine-6-carbox-
ylic acid) is a representative of third generation of fluoroquinolones. It
possesses bactericidal activity against Staphylococcus aureus, Strepto-
coccus pyogenes, Escherichia coli, Proteus mirabilis, Shigella spp.,
Haemophilus influenzae, Clostridium perfringens, and Streptococcus
pneumoniae. In vitro study proved synergistic activity of levofloxacin
with tazobactam against fluoroquinolone-resistant strains of Pseudo-
monas aeruginosa. Moreover, in vitro study proved synergistic activity
with oxacilin against MRSA [1–3]. Due to its high tissue concentrations
the third generation of fluoroquinolones can be administered once a
day [4]. Fluoroquinolones exhibit concentration-dependent killing
* Corresponding author.
E-mail address: aczyrski@ump.edu.pl (A. Czyrski).
best correlate with their bactericidal activity [5].
Sunitinib is a tyrosine-kinase inhibitor approved for the
treatment of patients with gastrointestinal tumor (GIST) and
advanced renal carcinoma (RCC). It is metabolized to N-desethyl
active metabolite (SU012662) [6–8]. Sunitinib is a CYP3A4 substrate.
Thomas-Shoeman et al. [9] reported that rifampicin caused 46%
decrease of sunitinib exposure. Rifampicin is CYP3A4 inducer. The
simultaneous administration of ketoconazole (CYP3A4 inhibitor)
leads to 51% increase of sunitinib concentration. What is interesting
is that the classic CYP3A4 inhibitor as grapefruit juice does not
influence the pharmacokinetics of sunitinib significantly [10].
The recent study conducted by Szałek et al. [11] proved that co-
administration of levofloxacin with sunitinib changes the following
pharmacokinetic parameters of sunitinib: Cmax and AUC0–1. The
study also proved the influence of levofloxacin on SU012662
(sunitinib metabolite) Cmax. The following study is to investigate
how sunitinib influences the pharmacokinetics of levofloxacin.
The increasing risk of bacterial infections in oncological patients

http://dx.doi.org/10.1016/j.pharep.2014.12.013
1734-1140/ß 2015 Institute of Pharmacology, Polish Academy of Sciences. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
 A. Czyrski et al. / Pharmacological Reports 67 (2015) 542–544 543

and the strong concentration-dependant activity of levofloxacin are the normally distributed variables were determined with the
the key factors of our study. Student’s t test and in other cases, the Mann–Whitney test was
applied. Correlations between the parameters were calculated
Material and methods with the Spearman Rank correlation coefficient for all non-
normally distributed values. A p value of <0.05 was considered
Reagents as significant.

Levofloxacin as a reference substance (Sigma–Aldrich,

Germany) and moxifloxacin as an internal standard (Santa Cruz
Biotechnology, USA) were used. Sunitinib (Sutent, batch number
P177H) was purchased from Pfizer Trading Polska Sp. z o.o.
(Warszawa, Poland). Levofloxacin (Tavanic, batch number:
2F349A) was purchased from Sanofi–Aventis (Warsaw, Poland).
Acetonitrile of HPLC grade was purchased from Merck
(Germany). Demineralised water (Milipore, France) was always
used. Triethylamine (TEA) was provided by Sigma–Aldrich
(Germany) and 85% orthophosphoric acid by Fluka (Germany).
The chromatographic separation was performed on RP18 HPLC
column (LiChroCART, Merck, Germany). The mobile phase was
acetonitrile:0.4% TEA solution (pH 3.0) in the ratio 24:76. The
excitation wavelength was 295 nm and emission wavelength was
490 nm [unpublished results].
Animals
New Zealand male rabbits, weighing 3.00  0.16 kg (mean  SD)
were used for experiments. All rabbits were kept in individual cages
located in the animal laboratory at the Department of Clinical
Pharmacy and Biopharmacy of University of Medical Sciences. They
were acclimatized for 2 weeks prior to the experiments and were
maintained under standard conditions of temperature (23  2 8C) and
humidity (56–60%) with an alternating 12 h light/dark cycles. New
Zealand rabbits were provided with 100 g of commercial pelleted diet
(Labofeed KB1: 9.8 MJ/kg metabolite energy, 16.00% total protein,
0.65% vitamin P, 15,000 JU vitamin D3 and 65 mg vitamin E) and tap
water ad libitum. All experimental procedures related to this study
were approved by the Local Ethics Committee of Medical University of
Poznań.
Evaluation of levofloxacin pharmacokinetics
The rabbits were divided into two groups (6 animals each): the
control group receiving levofloxacin and the investigated group
receiving levofloxacin and sunitinib. Levofloxacin was adminis-
tered intravenously in 30 min infusion. The dose was 20 mg/kg of
body weight. Sunitinib was administered per os at a single dose
25 mg [11]. The calibration curve for levofloxacin was linear within
the range 0.15–30.00 mg/ml (r = 0.999). The validation parameters
did not exceed the value of 15%.
Pharmacokinetics calculations
The plasma concentrations of levofloxacin enabled us to
calculate the pharmacokinetic parameters using WinNonLin
software (version 6.2, Pharsight, Mountainn View, CA, USA). The
non-compartmental technique was applied. The following param-
eters were calculated: elimination rate constant (kel), the total area
under the concentration–time curve (AUC1), half life (t0.5), Cmax,
Results
The aim of this study was to evaluate the impact of sunitinib on
levofloxacin pharmacokinetics. To the best of our knowledge this
kind of study has not been conducted yet. The pharmacokinetic
parameters are shown in Table 1.
Levofloxacin pharmacokinetics is best described by the two-
compartment model [12,13]. However Cao et al. [13] and Conte
et al. [14] used the non-compartmental analysis. In our study we
applied the compartmental analysis.
According to statistical analysis there were no significant
differences in Cmax, tmax, AUCtot, Cl, MRT and AUMC.
Sunitinib influences the elimination rate constant for levo-
floxacin. The statistically different increase of kel was observed in
the group where levofloxacin and sunitinib were co-administered
(0.25 vs. 0.18, p = 0.026) (Table 1). With the increase of elimination
rate constant the statistically significant decrease of half-life was
also observed for the group where sunitinib and levofloxacin were
co-administered (2.88 h vs. 3.99 h, p = 0.038). Sunitinib also
influences the volume of distribution. The statistically different
increase of Vd (p = 0.045) is observed in the group with sunitinib
(Table 1).
The statistical analysis proved that there was a statistical
correlation between the following five time-points: 0.25 h
(p = 0.035), 4 h (p = 0.009), 6 h (p = 0.003), 10 h (p = 0.004), 12 h
(p = 0.001) and AUC.
Discussion
These differences might be explained by much lower affinity of
levofloxacin to plasma proteins. Sunitinib and its active metabolite
bind to plasma proteins in 95% and 90% respectively [15]. Levo-
floxacin binds to plasma proteins in 40% [1]. There is potential
pharmacokinetic interaction in the phase of distribution between
sunitinib and levofloxacin, where sunitinib displaces levofloxacin
from the protein binding site. It leads to the increase of the free
fraction of the drug in serum and the free drug permeates to
tissues. According to Sheikh et al. [16] the protein binding of
levofloxacin strongly depends on the drug concentration within
the range 1–5 mg/ml (from 38% to 59%). At 5 mg/ml the binding
sites are saturated and no further increase is found. In our study we
observed much higher concentrations. During the first 2 h we
observed the decline in concentration from 19 mg/l to 5 mg/l. Due
to the strong binding affinity of sunitinib and its metabolite to
Table 1
The pharmacokinetic parameters of levofloxacin after 30 min bolus.
Pharmacokinetic Control group Investigated Statistical
parameter (n = 6) group (n = 6) analysis

tmax, clearance (Cl), area under the first moment curve (AUMC), and kel [h1] 0.18  0.04 0.25  0.05 0.026
mean residence time (MRT). t0.5 [h] 3.99  0.92 2.88  0.67 0.038
Cmax [mg/l] 18.70  2.23 18.42  3.84 NS
tmax [h] 0.58  0.00 0.58  0.00 NS
Statistical analysis AUC0!1 [h mg/l] 39.65  6.12 38.04  6.37 NS
Vd [l] 8.99  2.00 9.03  6.53 0.045
The statistical analysis was performed using Statistica version Cl [l/h] 1.70  0.69 1.56  0.24 NS
8.0 software (StatSoft Inc, Tulsa, OK, USA). Normality was MRT [h] 3.64  0.76 2.99  0.87 NS
AUMC [h2 mg/l] 157.17  48.48 126.36  49.32 NS
estimated with the Shapiro–Wilk test. The differences between
544 A. Czyrski et al. / Pharmacological Reports 67 (2015) 542–544
plasma proteins, the free fraction of levofloxacin increases. The
poor protein binding results in rapid elimination the drug from the
body [17]. The pharmacodynamic effect of fluoroquinolones
strongly depends on their concentration in serum. Fluoroquino-
lones exhibit concentration-dependant killing effect and the
pharmacodynamic parameters Cmax/MIC and AUC/MIC best
correlate with their bactericidal activity. Rapid elimination may
lead to their lower concentration in plasma and thus to the lack of
bactericidal effect [5].
The statistical analysis proved that limited sample strategy may
be applied. Forrest et al. [18] investigated optimal samples
strategies for intravenous administration of ciprofloxacin. He
suggested that the most optimal is taking three samples in the
following time intervals a near peak 15–30 min, 2.5 h and trough
concentration. However, for pharmacokinetic study they recom-
mended the strategy of five or even six samples. In our study we
observed the correlation between five time-points and it can be
optimal for drug monitoring. The use of AUC is limited by the large
numbers of blood samples for its determination. However, there
are populations of patients for which frequent phlebotomy might
be harmful (critically ill, elderly patients), unethical (pediatric) or
may have limited venous access [18,19]. The reduction of the
collected blood samples can be useful from the clinical and also
economical point of view. Strategies using a limited number of
samples are useful also in therapeutic monitoring of anti-
coagulant drugs [20] and immunosuppressants [21].
Conflicts of interest
The authors declare that there are no conflicts of interest.
Funding
This paper was supported financially by the Poznań University
of Medical Sciences.
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